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Arterial Injuries: in THR

- See:
        - Total Hip Replacement Menu:
        - Anastomosis of Lower Limb Arteries
        - Nerve Injuries in THR:
        - Acetabular Screw Placement:

- Discussion:
    - arterial injuries have been reported in 0.1% to 0.2% of all total hip replacements;
    - vascular injury is more common w/ the anterior approach, possibly because of retractor placement;

- Vessel Injury from Acetabular Screws:
    - see: acetabular screw placement
    - use of screws to fix an uncemented acetabular cup may injure intrapelvic vessels;
    - anterior & anterosuperior quadrants of the acetabular wall should not be perforated because of their close proximity to the neurovascular structures;

- Injury to External Iliac Artery and Vein:
    - screw placement: for acetabular component;
           - artery may be damaged by drilling into anterior superior quadrant of acetabulum;
           - external iliac vein accompanies the artery;
           - veins lies opposite the anterosuperior quadrant;
           - this has been lacerated during screw placement, resulting in large retroperitoneal hematoma;
    - injury from retractors:
           - psoas is interposed between anterior column of acetabulum and iliac artery;
           - as the psoas runs distally, the muscle thins and becomes more tendinous;
           - risk of vessel injury is decreased by placing retractors more proximally along anterior column where vessels are protected by muscular portion of psoas;
                   - risk of injury is increased when retractors are placed too far medially over anterior acetabulum proximal to transverse acetabular ligament;

- Obturator Artery:
    - obturator nerve, artery, and vein most frequently traverse lateral wall (quadrilateral surface) of the pelvis together, covered by parietal peritoneum, w/ nerve
             located most superior & vein most inferior;
    - neurovascular bundle lies opposite interoinferior quadrant of acetabulum;
    - injury to this artery may occur if the anterior inferior quadrant is instrumented, such as w/ placement of a retractor under transverse acetabular ligament
             into the superolateral aspect of the obturator foramen;

- Superior Gluteal Vessels:
    - injury to the superior gluteal artery can occur from screws placed in the area of sciatic notch;
    - to avoid damage notch should be gently palpated and protected w/ the surgeon's digit to avoid instrument protrusion into this area

Mechanisms of arterial injuries associated with total hip replacement.   

Vascular complications after total hip arthroplasty.   

Neural and Vascular Injury in Total Hip Arthroplasty.    

Thrombosis of the external iliac artery following total hip replacement. A case report.   

Acute ischemia of a lower limb following postoperative traumatic protrusion of an acetabular reinforcement device 

Common femoral artery intimal injury following total hip replacement. A case report and literature review

Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications.